Pediatric Episodic Case Write-Up
Student’s Name
Institutional Affiliations
Pediatric Episodic Case Write-Up
Patient Information:
Patient Initials: S.A. Age: 6 years Sex: Male Race: Hispanic
S.
CC: “My son has a stuffy and runny nose. He also has difficulty breathing, a cough, itchy eyes, and itchy ears and nose. He looks fatigued as evidenced by the lack of interest in playing and daily activities.”
HPI: S.A. is a 6-year-old male patient who has been brought to the clinic by his mother, The mother reports that her son has a stuffy and runny nose. He also has difficulty breathing, a cough, itchy eyes, and itchy ears and nose. He looks fatigued as evidenced by the lack of interest in playing and daily activities. These symptoms started 3 days ago. The mother indicates that she has not given S.A. any medications since the symptoms started.
Medications: None.
PMH: S.A. has a history of asthma which was successfully treated.
FH: Both parents are alive. S.A. does not have siblings. Grandparents are alive with no known clinical diagnoses.
SH: S.A. is the first born and the only child to his parents. He in kindergarten. He plays in open dusty fields with his friends every day after school.
Allergies: Mother indicates that S.A. is allergic to cold weather and dust.
Immunizations: S.A. has been vaccinated according to schedule as per is mother’s reports. His last influenza vaccine was given on 8/05/2022.
ROS.
General: Fatigued. No abnormal weight gain or weight loss.
Skin: Denies skin rashes or erythema. Denies changes in nail appearance and structure.
HEENT:
Head: Denies physical head injury or headache.
Eyes: Reports itchiness.
Ears: Reports itchiness.
Nose and Sinuses: Reports itchiness, stuffiness, and nasal drainage.
Mouth and throat: Denies oral lesions. Reports a cough.
Neck: Denies a swollen neck.
Lymphatics: Denies swollen lymph nodes.
Pulmonary: Reports nasal obstruction. Reports a history of asthma. Reports difficult breathing.
Cardiovascular: Denies chest tightness or chest pain.
Gastrointestinal: Denies diarrhea or indigestion.
Musculoskeletal: Denies muscle stiffness or joint pains.
Neurologic: Reports fatigue and reduced energy.
O.
VS: BP 100/70; P 90; R 18; T 34.5 degrees Celsius; Weight, 20.4 kg.
General: S.A. is alert and well-groomed. He is oriented to person, place, and time. S.A. is appropriately dressed for the weather.
HEENT: No evidence of physical injury on the head. No signs of ear blockage. Evidence of inflammation or redness in the conjunctivae of the eyes. Paleness and bogginess of the nasal mucosa. Enlarged turbinates with clear nasal discharge. Enlarged tonsils and evidence of erythematous throat.
Neck: Negative for injury, swelling, or evidence of goiter.
Gastrointestinal: Absence of abdominal distension. No bowel sounds.
Lungs/Respiratory: Positive for nasal congestion and airway obstruction.
Cardiovascular/Heart: No gallop. Absence of murmurs.
Musculoskeletal: Absence of joint pain or stiffness.
Neurological: Negative for motor or sensory deficits.
Laboratory tests and diagnoses:
- Sinus palpation: Swelling, tenderness, and pain signifies an infection (Bickley et al., 2020).
- Antibody test: The presence of IgE antibodies confirmed (Husna et al., 2022).
- Nasal septum inspection: Straight septum, no deviation or perforation (Bickley et al., 2020).
- Nasal smear test: Eosinophils detected (Husna et al., 2022).
- The use of a head mirror to assess turbinates: Evidence of enlarged nasal turbinates (Dains et al., 2019).
A.
Differential Diagnosis:
- Pediatric allergic rhinitis (primary diagnosis)
- Pediatric sinusitis
- Pediatric nasal polyps
- Pediatric turbinate hypertrophy
References
Bickley, L., Szilagyi, P., Hoffman, R., & Soriano, R. (2020). Bate’s guide to physical examination and history taking (Lippincott Connect). 13th ed. Philadelphia: Wolters Kluwers.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Husna, S. M., Tan, H. T., Md Shukri, N., Mohd Ashari, N. S., & Wong, K. K. (2022). Allergic rhinitis: A clinical and pathophysiological overview. Frontiers in Medicine, 9, 874114. https://doi.org/10.3389/fmed.2022.874114